Lumbar Sympathectomy:

Conventional Technique

Henry Haimovici

Introduced many decades ago as a method of treatmentfor ischemic and painful disorders of the

lower extremity,much controversy still persists over the physiologic effects, clinical indications, and long-

term results of lumbar sympathectomy. The first lumbar sympathectomy for arterial occlusive disease of

the lower extremity was performed in 1924 by Julio Diez of Buenos Aires (1). From this point on, the

history of lumbar sympathectomy has been one of mixed fortunes. Its place in the management of

vascular disorders underwent periodic reappraisals because of uneven clinical results. This became

especially relevant after the advent of reconstructive arterial surgery.

Neuroanatomy of the Lumbar Sympathetic Trunk

The standard anatomy textbooks indicate that, as a rule, the lumbar sympathetic trunk contains

four or five ganglia (2-4).

Ganglion LI is described as lying anterior to the bodyof vertebra LI, over the second lumbar

vertebra or anteriorto the intervertebral disk. The second ganglion (L2) has been described as lying

anterior to the body of the second lumbar vertebra. Ganglia below the second are common; the second

and the fourth are the more constant ones. The latter is usually located behind the origin of the iliac

vessels.

Kami of the first ganglion have a cephalic direction, the second has a transverse direction, and the

third and forth ganglia have a transverse or caudal direction.

Distribution of Sympathetic Innervation of the Lower Extremity

Completeness of anatomic denervation is important for achieving adequate sympathectomy of a

given segment of an extremity. Excision of the chain from L2 to L4, sometimes including LI, offers

satisfactory results. Removal of a lesser portion of the sympathetic chain may, however, prove to be

inadequate. The source of sympathetic fibers as related to the lumbar ganglia may be helpful in

determining the extent of the sympathectomy. Thus the first lumbar ganglion supplies the sympathectic

innervation of the thigh and parts of the leg. The ablation of the second and third lumbar ganglia

denervates the posterior aspect of the thigh, the leg, and the foot.

Criteria for Completeness of Sympathetic Denervation

Evaluation of the degree of denervation following a lumbar sympathectomy relies upon two main

physiologic effects:

1. vasomotor responses as determined by skin thermometry; and

2. cessation of the secretory activity of the sweat glands (5,6).

indications

Indications for lumbar sympathectomy are limited essentially to patients with nonreconstructible arterial

disease or vasospastic conditions of the leg and foot. Predicting the effects of a sympathectomy upon the

circulation of the lower extremity, especially the foot and toes, is essential for determining the operative

indications. Essentially, one has to evaluate properly:

1. the collateral circulation or its potential availability,

2. the vasomotor activity of the extremity, and

3. clinical findings,

all of which may provide in most instances a fairly accurate prediction of the operative results (7). The

physiologic effects of a lumbar sympathectomy still remain ill-defined, as attested by a number of reports.

Interpretation of the blood flow increase effect has been called into question. Indeed, investigations of

arteriovenous (AV) shunting following lumbar sympathectomy have raised the question of the therapeutic

value of its nutritive blood flow to the denervated tissue, especially to the skin. It should be noted that

such data were obtained primarily in acute animal experiments, which disclosed that after sympathectomy

there is an increased AV flow with no change in total capillary nutritive flow, to both skin and muscle (8).

Other investigations, however, are at variance with these results. One of the reasons invoked is the

experimental model, and the other is the possible lack of correlation with the arteriosclerotic human

extremity. Thus, while in the above-mentioned experimental modelthe arterial tree was undisturbed, by

contrast, when the femoral arteries were ligated so as to mimic ischemic clinical conditions, significant

increase in tissue blood flowwas obtained following sympathectomy (9). The failure of sympathectomy to

relieve intermittent claudication in the majority of cases has been interpretedas a lack of sympathetic

innervation of those vessels of skeletal muscle.

In the presence of advanced arterial disease due to diffuse lesions not lending themselves to

reconstructive vascular surgery, sympathectomy may be the only measure of limb revascularization. In

these cases, its role and greatest effectiveness reside in the physiologic ability to increase the collateral

system for improving and preserving the viability of the skin.

Based on our experience and that of others, relief of rest pain and prevention of major

amputations in a significant percentage of patients attest to the effectiveness of this procedure, even in

patients with advanced ischemic changes (7,9-11). It should be pointed out that, during the critical

postoperative period, meticulous care of the foot lesions, cessation of smoking, and avoidance of any

other vasoconstrictor influence may greatly enhance the effectiveness of the sympathectomy.

The role of diabetes mellitus is generally recognized as an accelerating and aggravating factor in

limb and life prognosis. Indications of lumbar sympathectomy in patients with diabetes are questionable

because of the frequency of "autosympathectomy" in such patients. The diffuse nature of the

arteriosclerotic process may account primarily for the greater severity of isehemic changes in diabetic

as compared with nondiabetic patients. This is substantiated by arteriographic studies of the lower

extremity (12). As shown by our own findings, occlusion of the distal arterial tree (popliteal, tibials), poor

or absent runoff, and inefficient collaterals are more prevalent among diabetic patients (8,13).

In a number of reports, and in our own study, it is apparent that sympathectomy in a certain

number of cases may have only a delaying action, as it does not arrest the downgrade progression of the

atherosclerotic process.

Contraindications to lumbar sympathectomy are rapidly progressing ischemic lesions and poor general

condition of the patient. Unsatisfactory results may be avoided by adhering to the criteria for selection of

patients as outlined above.

Lumbar sympathectomy alone or in combination with reconstructive arterial surgery, however,

may be a valuable procedure in selected patients with advanced arterial insufficiency (8).

The method of choice for either unilateral or bilateral lumbar sympathectomy is by the

extraperitoneal exposure.

Two approaches are most convenient and simple: 1) anterior transverse and 2) anterolateral. The

former is the most commonly used. The latter is employed in conjunction with exposure of an iliac vessel.

Anterior Transverse Exposure For right lumbar sympathectomy (see Figs. 54.1 and

54.2), general endotracheal anesthesia is preferred, although epidural or spinal anesthesia is often used in

certain patients.

The number and location of the ganglia are variable.From a practical point of view, the chain

should be removed between a point of emergence near the diaphragmaticcrura and the point of

disappearance beneath thecommon iliac vessels. This segment usually comprises the essential L2, L3, and

L4 ganglia. For denervation of the anterior surface of the thigh, LI should also be included (Fig. 54.3). In

some instances the crus of the diaphragm may have to be divided in order to reach LI.

In some patients, the sympathetic trunk may be obscured by overlying fibrous bands. When

invisible, the trunk may be located by digital palpation over the vertebrae.

Incision of the fibrous layer is then necessary before the chain is exposed and isolated.

On the right side, the inferior vena cava covers the sympathetic trunk and hides it completely from view

before its retraction. The left sympathetic chain is always more readily exposed when the adipose and

lymphatic tissue masses are reflected medially toward the aorta.

The transversalis fascia and the peritoneum are often inseparably adherent anteriorly and

separated laterally by the properitoneal fat. If inadvertently incised or opened during the separation, the

peritoneal rent should be promptly closed. The peritoneum should be reflected toward the midline before

reaching the anterior surface of the psoas. Otherwise, the dissecting fingers may stray into the gutter

between the quadratus lumborum and psoas muscles.

The ureter with the genital vessels is incorporated in and retracted with the parietal peritoneal

leaf. These structures are easily demonstrable and should not be confused with the lumbar

sympathectomy chain. The operative techniques are summarized in Figures 54.4,54.5, and 54.6.

Operative Pitfalls

Injury to the structures adjacent to the sympathetic chain, if minor and consisting of bleeding

from lumbar vessels, should be treated by temporary compression with gentle packing, to be followed

immediately by the use of clips.

Inadvertent rupture of a lumbar artery may be more difficult to control and may necessitate

temporary occlusion of the aorta in order to secure the stump of the ruptured lumbar vessel. A tear in the

inferior vena cava or abdominal aorta or iliac vessels is by far a more serious complication because of

potentially significant loss of blood.

Compression or clamping of the aorta or compression of the inferior vena cava is necessary for

control of bleeding before repair of the vessels is carried out. Likewise, injury to the ureter should be

recognized promptly in order to repair any rent.

Removal of the genitofemoral nerve or iliolumbar nerve, mistaken for the sympathetic trunk, may

cause less tragic consequences but may be responsible for some neuritic pain and, obviously, results in

failure of the desired sympathetic denervation.

Postoperative Care

As a rule, after a successful sympathectomy, the extremity becomes warm and dry within a matter

of hours. Painful ulcers or rest pain usually subside in the majority of cases.

Postoperative abdominal distention due to a paralytic ileus may be a source of discomfort to the patient

for 2 to 3 days. In such instances, administration of 250 or 500 fig of neostigmine (Prostigmin) every 6

hours, combined with intermittent use of a rectal tube, may promptly alleviate the discomfort.